Morals, Suicide, and Psychiatry: A View from Japan

MORALS, SUICIDE, AND PSYCHIATRY: A VIEW FROM JAPANOriginally published in Bioethics (vol. 16, no.5, September 2002) JEROME YOUNGABSTRACT In this paper, it is argued that within the Japanese social context, the act of suicide is a positive moral act because the values underpinning it are directly related to a socially pervasive moral belief that any act of self- sacrifice is a worthy pursuit. The philosophical basis for this view of the self and its relation to society goes back to the writings of Confucius who advocated a life of propriety in which being dutiful, obedient, and loyal to one's group takes precedence over the desires of the individual selves that make up the group. It is argued that this philosophical perspective poses formidable challenges to Japanese psychiatry (which accepts a contrary perspective) because, as western psychiatry is based on the concept of autonomous individuality, the Japanese conceive of the self as socially embedded. Because suicide in Japan is viewed as a potentially honorable, virtuous, and even beautiful act of self-sacrifice expressing one's duty to one's group, the western perspective is quite foreign to the Japanese self-conceptual framework. Therefore, since Japanese psychiatry and law have embraced the western medical tradition of viewing suicide as a non-rational response to mental illness, which runs counter to the cultural view that suicide is a moral (and rational) act, it is argued that western explanations of suicide present significant cross-cultural problems for Japanese psychiatry.INTRODUCTION In the West, suicide has been viewed at various times as a religious, a moral, a legal, or a medical problem (1). Nowadays the act of suicide is ipso facto evidence of mental illness (2). As Appleby rather confidently states, “it has been shown that most, if not all, suicides have suffered from some form of psychiatric disorder before death” (3). While his confidence is reassuring, in Japan the situation is different because of a persistent evaluative stance toward voluntary death as a positive moral act. In Japan, suicide is not seen as the denial of the value of life (4), but as an affirmation of the value of one's moral duty to others (giri). The Japanese sense of duty is driven purely by social context, not by God or a moral law, and makes the act of suicide the logical outcome of a complex interplay of social factors and has little, in most circumstances, to do with illness. For this reason, Japanese psychiatrists and lawmakers are faced with a difficult situation because, while they endorse the spirit of the western perspective, culturally suicide is an act driven by moral concerns. Underlying this conflict between the western and Japanese views of suicide is a deeper philosophical problem about the nature of the self. Western psychiatry is based on the concept of autonomous individuality, but this concept is completely outside the Japanese self-conceptual framework. For the Japanese, the individual is socially embedded and, as a consequence, group membership is of central importance. Hence, while the main clinical difficulty for western psychiatrists in evaluating suicidal patients is “judging the rationality of the ‘patient’” (5), there is another difficulty to be considered in the Japanese context. Should Japanese psychiatrists use a western standard of rationality, or should they use a Japanese one? The current western standard would indicate that suicidal behavior is, by and large, irrational and merits psychiatric intervention. However, this contradicts Japanese sentiment about suicide as a moral act of self-sacrifice dictated by the social network to which the self belongs. The Japanese standard of rationality, one derived from ancient Confucian principles about moral behavior (6), would indicate that the act is rational and morally appropriate under the specific circumstances in which the agent acts because any act of self-sacrifice is highly valued. It is through self-sacrifice that the individual shows his or her moral worth because he or she recognizes there is something greater than the ‘I’, namely the harmony (wa) of the group. Therefore, since suicide is perceived socially in Japan as a moral rather than a medical concern, there is a cultural precedent for dismissing medicine having any role in the affair. To western eyes, the Japanese standard of rationality, in so far as it permits suicidal behavior, may seem irrational, but it is, in fact, a morally legitimate alternative to the western standard. In this article, it is argued that suicide in Japan is never simply a matter of ending one's life, is never simply the denial of the value of life, and is not seen as a consequence of mental illness. Rather, it is the natural consequence of Confucian moral sentiment that self-sacrifice is a virtue. For the Japanese, self-sacrifice is, as Brentano would express it, a “rule of the heart” (7). The values giving moral legitimacy to suicide run deeper than the act of suicide itself because self-sacrifice plays an integral role in everyday Japanese life. Every individual must make sacrifices in order to maintain social harmony. The cultural precedent for rational suicide in Japan is the ritualistic suicide (seppuku) of the samurai warrior. In the samurai's sacrifice of self we find a romantic image of suicide as a heroic, moral, and aesthetic deed. Modern suicide, while perhaps not as dramatic as its historical predecessor, retains its strong moral overtones and remains a moral solution to moral problems. As a consequence, there are serious doubts about the social acceptance of the spirit of the (westernized) Japanese mental health law medicalizing the act. Because suicide is so positively evaluated in Japan, and because at its basis is a deeper moral commitment about the relationship between the self and society, medical and legal efforts to prevent or reduce the number of suicides seems only possible with a dramatic change in value orientation.ALTERNATIVE CONCEPTUAL FRAMEWORKS OF SELF For a great many years, the Japanese have been assimilating western ideas, values, and ways of doing things. By outward appearances, the Japanese seem very westernized, in fact. How- ever, traditional Japanese values continue to exert an influence on what people believe, how they act, and how they look at the world. There is nothing particularly unique about these values, but they are certainly different from those found in the west. The fundamental way in which these traditional values shape Japanese experience is in the way a person conceptualizes the self and its relation to society. At the core of the Japanese experience is a Confucian view that the individual exists only by the good grace of the group to which he or she belongs, that one must be dutiful, obedient, and loyal to the group. As Kishimoto said, “For principles of moral conduct, [the Japanese] rely on the Confucian code” (8). As a result of this orientation, Japanese moral concepts are different, at least in terms of emphasis, from their western counterparts. In the west, the individual is conceived of as autonomous, independent, and free, and, moreover, as possessing inalienable rights. What we find in Japan, in contrast, is a conception of the individual as socially embedded, as dependent on others, and as compliant to other's wishes (sunao) (9). As the individual's “interest is absorbed in the interest of the collectivity to which he belongs” (10), the self in Japan is not considered an independent entity, as it is in the west. The self is implanted into a network of other selves formed into various groups (e.g., family, school peers, friends, community, or company). Each individual receives benefits (on) from the group and has unwritten duties (giri) for which he or she is responsible because through their fulfillment social harmony (wa) results. The emphasis on group harmony makes the wishes or desires of the individual secondary to the whole. Hence, while in the west the concept of self is predicated on autonomous individuality, in Japan the concept of self is predicated on a harmonious collectivity. Because of this different self-conceptual framework, it should come as no surprise that the idea of inalienable rights, of something each individual has an absolute claim to, is alien to the Japanese social context (11). The Japanese emphasis on harmony is a moral value quite different from anything found in the west. Because the Japanese conception of self is collective, the individual is, therefore, not considered an ‘end in itself’. Rather, the self is merely one part of the whole and is, thereby, not as important as the group he or she belongs to. For this reason, self-sacrifice (kenshin) is a key moral value in the Japanese context. However, this self-sacrifice should not be confused with a utilitarian type of self-sacrifice. Utilitarianism, such as that advocated by Mill (12), aims to get people to act in such a way that their actions produce the greatest happiness for the greatest number of people and self-sacrifice is, for this reason, sometimes a necessity. In contrast, for the Japanese, self-sacrifice is an everyday occurrence because without it social harmony is not possible. Hence, whatever maximizes harmony is to be pursued because it is what must be done. To achieve harmony, to fulfill one's duty to the group, often entails sacrificing the desires or wishes or preferences or happiness of the self for the sake of the good of the whole group. Japanese self-sacrifice, while mostly benign, does not preclude its more lethal variety, i.e. suicide. Thus, we can see why Kant's reasoning that suicide is incompatible (i.e., a logical contradiction) with the idea of humanity as an end in itself has no persuasive power in the Japanese context (13). In Japan, suicide is elevated to an honorable and virtuous act of self-sacrifice because the group is of central importance. The self becomes, then, a means to a greater end, i.e., group harmony. The Japanese self is edified through others (i.e., the group); one sacrifices one's own desires for the good of the whole because the harmony of the group will, in the end, lead to virtue to all therein (14). Therefore, Kant's and Mill's moral philosophies are of very little use to the Japanese because they are predicated on a very western view of the self in which personal liberty and individuality are primary. Instead of acting according to some intellectual utilitarian calculus or Kantian categorical imperative, the Japanese act according to rules of the heart, according to the principle of Wa (harmony). Because the Japanese conception of self is intertwined with the collectivity, the concept of moral duty (giri) is also quite different from the way it is conceived of in the west. Kimura defines giri as ‘a sense of duty, obligation, a debt of gratitude, a sense of honor, responsibility, social courtesy, demand of custom, for the sake of justice, for decency's sake’ (15). As this definition suggests, the Japanese social system is permeated with duties. However, even though Japanese duty has the moral force of a command (i.e., it is simply something that must be done), it extends no further than to one's in-group/s. A Kantian sense of duty, therefore, has no resemblance to the Japanese sense of duty. Kant's categorical imperative is too strong because it advocates a universal rule of conduct whereas the Japanese advocate rules of conduct that are relative to the group (whether it is the family unit, school friends, clubs, the neighborhood, company, or organization). These duties (which are best thought of as `rules of the heart') help to guide conduct, moral or otherwise, so that as groups form the people are able to work together in harmony (wa). Thus, while the general population shares in this collective value-orientation, the Japanese sense of duty tends to be localized or situational and not universal. In this section, I argued that the situation in Japan is such that it offers an alternative conceptual framework for thinking about the self and its relation to society. Furthermore, I argued that because of this difference, the Japanese context offers an alter- native framework for thinking about morals. Since the Japanese conception of duty and self-sacrifice are related to a concern for social harmony, I argued that western moral philosophy, either the Kantian or utilitarian variety, is too individualistic to capture the nuances of the Japanese ‘collectivistic’ moral perspective.THE MORAL LOGIC OF JAPANESE SUICIDE: REDEMPTION THROUGH SELF-SACRIFICE In the West, suicide has been seen as a violation of social trust, as an act to evade social responsibility, and as an act against one's duty to God. However, in Japan, the act of suicide is perceived as acceptable, good, and rational, especially, as Lifton et al. argued (16), ‘when used to take social responsibility for one's acts.’ The act of suicide, therefore, has a redemptive, moral quality to it. The source for this positive evaluative stance is two-fold. First of all, it derives its moral and philosophical strength from Confucian edicts about a life of propriety. Secondly, it draws on a long tradition of ritualistic suicide (i.e., seppuku). While seppuku is rarely done today, the values surrounding the act still resonate in the minds of modern Japanese because these values are integral to the Japanese moral ideal of virtue. As self-sacrifice for the sake of harmony is a socially pervasive value, suicide becomes another way in which the self is sacrificed for the greater good of a harmonious whole, or unit, or collectivity to which the person belongs and to which he or she is duty-bound. Ohnuki-Tierney argued that the Japanese idealize suicide to such an extent that ‘death is transformed into a cultural institution -- a triumph of culture over nature’ (17). Because the Confucian values that helped to shape samurai moral conduct play an equally important role in contemporary Japanese moral conduct, we can see continuity between seppuku and modern variations of suicide. The suicide of the samurai was a virtuous act, which would redeem the samurai in the eyes of others, because he fulfilled his social duty (giri). Contemporary suicide, likewise, has a moral logic to it because it centers on a person fulfilling his social obligations or duties and is, thus, a morally purposeful act. Suicidal self-sacrifice reached its highest, most developed, form in the ritualistic suicide (seppuku) of the samurai warrior. This form of suicide was the ultimate purposeful act: it was a well thought out, carefully orchestrated, rational thing to do. If a samurai was unable to fulfill his duty as a warrior, then he had the opportunity to redeem his honor by committing seppuku because it was ‘the last honor given to a samurai whose conduct deserved death’ (18). To commit seppuku, the samurai would take a short knife, plunge it into his abdomen (hara) and disembowel himself. Philosophically speaking, the reason the samurai would cut his abdomen is because the Japanese think of the abdomen as the seat of the soul (19). By cutting the abdomen, the samurai would expose his soul and show his purity (keppaku). Since the act involved exposing the soul, great care was placed on exactly how it should be performed and it became an aesthetic act. ‘The point of concern,’ Kishimoto argued, ‘was the manner of committing it. If one could commit suicide in a fine self-composed manner, it could be taken as a respectable achievement’ (20). Being self- composed in the act of suicide indicated how important the actor thought others' perception of the act was. ‘Seppuku was not a mere suicidal process,’ as Nitobe argued, ‘. . . it was a process by which warriors could expiate their crimes, apologize for errors, escape from disgrace, redeem their friends, or prove their sincerity’ (21). Hence, the act of seppuku could be admired and respected by others because it transformed a disgraced life into a virtuous one. This self-sacrifice is the logical consequence of a person accepting responsibility and, at the same time, is a profound statement about the person's moral character. A recent example of suicide in which the agent was motivated to act to clear his name and to redeem his honor was the suicide of the world-famous film director Juzo Itami, 64, in 1997. The circumstance leading up to Itami's suicide was the forthcoming publication of a story in a weekly magazine alleging that he had been having an affair with a 26-year-old woman. He denied the report to the magazine, but they told him the article would be published anyway. On the eve of the publication, he jumped to his death. He left behind a suicide note in which he said ‘I will prove my keppaku (purity/innocence/integrity) by death. There is no other way to prove it but with death’(22). Here, like with the samurai of old, suicide was a way to preserve honor, to prove sincerity, to redeem himself in the eyes of others. Itami's suicide was an expression of duty (giri) to his name and honor. The public was shocked and saddened by his death (he made great movies!), but they could empathize with his sentiment and, one would believe, Itami knew they would understand perfectly why he acted as he did. The predilection of the Japanese to act in groups can also be seen in the act of suicide itself. As DeVos commented, ‘there is a readiness in Japan to commit suicide “with” others’ (23). This is evident in the frequency of parent-child or family suicide (oyako/ ikka shinju) (24). In these instances, feelings of shame, dishonor, or disgrace are key motivating factors. With family suicide (ikka shinju), the shame a family experiences frequently relates to economic problems; rather than feeling shame or disgrace because of living at a lower economic level, families will commit group suicide to save face. With parent-child suicide (oyako shinju), the majority of cases involve a mother and her children. In these cases, the mother frequently feels shame because of her husband's infidelity and seeks to counter her sense of dishonor or disgrace by killing herself and her children, and, thereby, gain sympathy from others (25). These forms of suicide may seem bizarre and exceptional to westerners but ‘the family is a stronger emotional unit than the individual selves who comprise it’ (26), so ‘the entire family and its status are fused with the sense of self in the suicidal act’ (27). It seems that parents would rather kill their children than leave them ‘without parental protection’ (28). Thus, in committing group suicide, parents are, in effect, doing the dutiful thing by taking responsibility (giri) for their children rather than burdening society with their upbringing. Difficult though it may be for westerners to fathom, dying together has a romantic quality that appeals to Japanese sentiment (29). It is purposeful and value-laden: others can empathize and appreciate it. In this section, I argued that Japanese suicide is a purposeful act that has a redemptive, moral quality to it. I have suggested that there is a moral continuity between the motives for contemporary suicide and those of the samurai. The reasons for suicide, whether in the past or present, are value-laden. Suicide can be understood as the logical, rational outcome of the Japanese sentiment that, when the social situation dictates, suicide is a morally appropriate act in which the self is sacrificed out of a sense of duty. By committing suicide, a person is accepting responsibility for his or her life, is making a definitive statement about his or her moral character, and is engaging in an act (i.e., self-sacrifice) that is a pervasive, though mostly non-lethal, aspect of everyday life in Japanese society. For these reasons, though people may occasionally express disapproval of the act of suicide, in their hearts they empathize with it because it appeals to deeply held moral beliefs about propriety and self-sacrifice.THE JAPANESE MENTAL HEALTH ACT, PSYCHIATRY, AND SUICIDE When we turn to Japanese law and psychiatry, we find a picture of suicide quite at odds with the pervasive cultural sentiment outlined above because what Japanese lawmakers and the psychiatric profession have done is to follow the western example and make it a sign of mental illness. The works of Emil Kraepelin, in particular, have exerted a great influence on Japanese psychiatry (29) and helped to cement the clinical connection between mental illness and suicide. Early in his Lectures on Clinical Psychiatry, Kraepelin made it quite clear that the mentally ill are a danger to others and to themselves. He said, ‘All the insane are dangerous, in some degree, to their neighbors, and even more so to themselves. Mental derangement is the cause of at least a third of the total number of suicides ...’(30). The persistence of a positive cultural attitude toward suicide, however, presents problems for clinicians and lawmakers alike because, while they endorse the conceptual link between suicide and mental illness, the average Japanese citizen is still influenced by, and lives according to, values which see any act of self-sacrifice as morally appropriate. Though a person may commit suicide out of a deep sense of duty, the Japanese Mental Health Law (31) makes that person into a madman: this runs counter to tradition and popular sentiment of viewing suicide as a potentially beautiful act of redemption. Thus, the traditionally positive view of suicide contradicts the imported idea that those who either attempt or commit suicide are mentally ill. The Japanese Mental Health Act poses a number of conceptual obstacles that are culturally difficult to overcome. First of all, there is the whole question of mental illness itself. Since the idea of mental illness was imported from the west, the law acts as a tool to force people to accept a view quite foreign culturally. Since there is no hard and fast distinction between the mind and body for the Japanese (32), accepting the idea of mental illness is more difficult than it may at first appear. Perhaps because of this, mental illness is highly stigmatized in Japan and is not recognized as a ‘real’ illness but as a weakness of the will (33). A further conceptual complication to accepting the spirit of the law is the way it defines mental illness; to wit, mental illness is ‘schizophrenia, intoxication psychoses, mental retardation, psychopathic personality disorder and other psychotic diseases’ (34). Psychotic disorders are especially susceptible to negative reactions because of the pejorative nuances of the Japanese words (35), making such a diagnosis as fearful as a diagnosis of cancer (36). In addition to these conceptual obstacles, there are also practical ones involving the involuntary commitment of suicidal patients. The Mental Health Act leaves the power to commit a person involuntarily up to the family (or protector) and the hospital. The Act stipulates that anyone who is responsible for the mentally ill person, who has a legal duty (gimu) (37) to support him, is his ‘protector’ (hogosha) (38). This protector can be a guardian, a spouse, a person with parental rights, or someone appointed by the court. It is the protector's duty (gimu) to support the mentally ill person, to ensure he receives medical care, and to make sure he does not hurt himself or others (39). The Act states further that a person may be incarcerated in a mental hospital against his will if a medical exam proves that he has a mental illness or if he may be a threat to himself or others (40). The fact that the family is involved in committing family members is not too surprising because, traditionally, the family has had to bear the burden of care for ill family members (41). However, since the protector is supposed to guard the interests of the patient, there is a question of conflict of interests, especially with someone who has attempted suicide. Even though there is cultural acceptance of suicide, there is the practical difficulty that the person's family may not help the ‘ill’ family member get professional help. The reason for this is that the family may experience a certain sense of shame or disgrace in reaction to any family members who attempt suicide but do so incompetently. Family members may have negative feelings toward a family member who failed in suicide because ‘society's reaction is evidently more important to them than their own family member’ (42). A failed suicide brings further shame on the person and his family because the deed does not bring honor or redemption but, instead, calls more attention to the individual (and his family), further separating (alienating) that person (and the family) from the collectivities to which they belong. Because suicide is an act with strong moral overtones, and because it has not been traditionally linked to mental illness, families are probably more reluctance to attribute some psychological ‘despair’ (43) or ‘psychache’ (44) to failed acts. What this means clinically is that someone who has attempted suicide is not likely to get sympathy from his family and, thus, not likely to get psychiatric attention because, by involving psychiatrists, a family is admitting that one of their kin has a weak will something already evident in the failed suicidal act itself. For these reasons, families are more likely to believe the failed suicide and any subsequent admission of mental illness only compounds the shame or disgrace brought on the family. In this section, I argued that the Japanese Mental Health Act follows the western example by medicalizing suicide, treating it as a non-rational response to a mental illness. I argued that the spirit of this law runs counter to the pervasive cultural values that regard suicide as a rational action in which the self is sacrificed for the sake of duty to one's immediate groups. Because of this conflict, I argued that the law has serious conceptual and practical difficulties. Conceptually, mental illness is stigmatized and regarded as a weakness of the will, not a real illness. Practically, the manner in which a person can be committed involuntarily is vulnerable to a conflict of interest because family members are often the ones who will do the committing but they may be reluctant to do so because of the added shame and disgrace it entails. Thus, in order for the law to be truly effective will require a fundamental shift in how the Japanese as a people see mental illness and suicide.CONCLUSION Even though the Mental Health Act aims to assert the importance of mental health and assert that everyone has a legal duty (gimu) to help the mentally ill, and even though it codifies the connection between mental illness and suicide, it is another matter for the public to accept it. Implicit in the Mental Health Act is the sense that an individual is autonomous and that anyone who attempts suicide is irrational. Yet, Japanese cultural values are collectivist and do not preclude suicide being rational -- in fact, there is a moral logic to it because all acts of self-sacrifice are valued as virtuous. In the Japanese social context, suicide is not seen as an ‘either/or’ proposition, as a sign of mental illness, or as a wanton act, but is a morally virtuous act because it is the logical outcome of a desire to fulfill one's duty to others (giri). I argued that the strong cultural acceptance of self-sacrifice for the sake of group harmony makes suicide, the ultimate act of self-sacrifice, a very difficult problem to address clinically. Because the values related to the moral legitimacy of suicide run deeper than suicide itself, suicide will remain a difficult problem for psychiatrists. Simply importing western values into the law and into clinical practice is not likely to change a cultural view about self-sacrifice that has existed for centuries. 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